Initial Client Intake Forms

Elizabeth Ross, LMFT, LPC

Download, complete, sign, date and bring each of these forms to your first appointment:

INTAKE Form: Please print and sign

 

QUESTIONNAIRE: Please print and sign. If the client is a child, please enter his/her name on the "client" line. If you are bringing more than one child, please complete a form for each child.

DISCLOSURE STATEMENT: Please print and sign. If the client is a teen the age of 12 or over, he/she must ALSO read and sign this form.

 

PAYMENT POLICIES: Please print and sign.

 

INSURANCE: There are no insurance companies that I am currently a provider for. Sometimes insurance companies will provide a single case agreement to a provider or approve out of network benefits. It is the responsibility of the client to get these authorizations. If your insurance requires pre-authorization to cover the cost of therapy it is your responsibility to obtain it.  It is your responsibility to know what your benefits include, if you have a deductible to meet and if so how much that is. Also it is your responsibility to know what your co-pay is.

 

HIPPA ACKNOWLEDGEMENT: Please print and sign

 

HIPPA DOCUMENT: Please read. Print ONLY if you'd like to keep a copy for your records.

©YOUnify Counseling